CDC Colorectal Cancer Control Program (CRCCP)

IOM Committee on Integrating Public Health and Primary Care

August 11, 2011

National Center for Chronic Disease Prevention and Health Promotion Division of Cancer Prevention and Control

Marcus Plescia, MD, MPHDirector, Division of Cancer Prevention and Control

National Center for Chronic Disease Prevention & Health PromotionCenters for Disease Control and Prevention

Outline

• The case for colorectal cancer screening

• Integrated approaches of CDC screening

programs

• Addressing Disparities

• Interface with Primary Care

Priorities among

effective clinical

preventive services

1. Aspirin chemoprophylaxis

2. Childhood immunization series

3. Tobacco use screening and briefintervention

4. Colorectal cancer screening5. Hypertension screening

6. Influenza immunization

7. Pneumococcal immunization

8. Problem drinking screening and brief counseling9. Vision screening – adults

10. Cervical cancer screeningMaciosek MV, et al. Priorities among effective clinical services: results of a systematic review and analysis. Am J prev Med 2006;31:52-61

Cancer Screening in the US Needs Improvement

q 22 million adults aged 50–

75 need to be screened

for colorectal cancer

q Insured are almost twice

as likely to get screened

as uninsured

Centers for Disease Control and Prevention (CDC). Vital signs: colorectal cancer screening among adults aged 50-75 years - United States, 2008. MMWR Morb Mortal Wkly Rep. 2010 Jul 9;59(26):808-12.

Late-Stage Cancer Diagnosis, 2004-2006(regional & distal stage combined)

q Almost half of the colorectal and cervical cancer cases in the U.S. are diagnosed at late-stages of the diseases

q Preventable cancers are not being diagnosed when treatment is most effective

Centers for Disease Control and Prevention. Surveillance of Screening-Detected Cancers (Colon and Rectum, Breast, and Cervix) —United States, 2004–2006. MMWR 2010;59(No. SS-9):[1-25].

Potential Mortality Reduction from Increased Screening, Risk Factors, and Treatment

Vogelaar I, van Ballegooijen M, Schrag D, Boer R, Winawer SJ, Habbema DF, Zauber AG. How Much Can Current Interventions Reduce Colorectal Cancer Mortality in the U.S.? Mortality Projections for Scenarios of Risk-Factor Modification, Screening, and Treatment. Cancer 2006;107:1624–33.

CDC has extensive experience partnering with primary care for cancer screening

CDC has well

established &

effective

cancer

screening

infrastructures

across the US

CDC Cancer Screening Provision Delivery Systems

CA

ID

OR

WA

MT

WY

UTCO

NM

TX

OK

KS

NE

SD

NDMN

WI

IA

IL OHIN

KY

WVVA

NC

GA

FL

ALMS

MO

AR

LA

NV

MI

PANJ

NY CTMA

VTNH

ME

TNSC

RI

AZ

DCDEMD

HIHI

AK

AMERICAN SAMOANORTHERN MARIANA ISLANDSGUAMPUERTO RICOREPUBLIC of PALAU

American Indian Initiative:

Arctic Slope Native Assn, Ltd – North Slope Borough, Barrow, AKCherokee Nation – Tahlequah, OKCheyenne River Sioux Tribe – Eagle Butte, SD

Kaw Nation – Kaw City, OK

Native American Rehabilitation Assn of the Northwest, Inc

Poarch Band of Creek Indians – Atmore, ALSouth Puget Intertribal Planning Agency – Shelton, WA

Hopi Tribe – Kykotsmovi, AZ

Navajo Nation – Window Rock, AZ

Yukon-Kuskokwim Health Corp – Bethel, AKSoutheast Alaska Regional Health Consortium – Sitka, AK

Southcentral Foundation – Anchorage, AK

68 NBCCEDP Screening Delivery Systems

CA

IDOR

WA

MT

WY

UTCO

NM

TX

OK

KS

NE

SD

NDMN

WI

IA

IL OHIN

KYWV

VA

NC

GAALMS

MO

AR

LA

NV

MI

PANJ

NY CTMA

VTNH*

ME

TN

SC

RI

AZAK

DCDEMD

HIHI

American Indian Initiative:

Arctic Slope Native Assn, Ltd – North Slope Borough, Barrow, AKNative Inupiat Eskimos

Alaska Native Tribal Health Consortium, representing:•Maniiliaq Association•Norton Sound Health Corporation•Chugachmuit•Bristol Bay Area Health Corporation (BBAHC)•Aleutian/Pribilof Islands Association (APIA)•Kodiak Area Native Association (KANA)•South East Alaska Regional Health Consortium (SEARHC)•Ketchikan Indian Community (KIC)

South Puget Intertribal Planning Agency – Shelton, WARepresenting 7 tribes in southwest Washington

FL

Southcentral Foundation, AKCook Inlet regional Corp, Inc

29 CRCCP Screening Delivery Systems

NBCCEDP and CRCCP services are delivered by over 22,000 clinical providers

Delivery Systems

u CHCs, FQHCsu Private physicians & physician

practicesu Health plansu Cancer centersu Tribal health clinicsu Local health departmentsu Minority health clinicsu Charity hospitals

CHCs/FQHCs…u Contract w/CDC grantees to

provide colorectal, breast & cervical cancer screening

u Participate in performance monitoring system

u Outreach and Patient Navigation

CDC Colorectal Cancer Control Program

• Program Goal– To increase colorectal cancer

screening to 80% among those aged 50 and older by 2014

• Program Development– Informed by the National

Breast and Cervical Cancer Control Program (NBCCEDP) and the Colorectal Cancer Screening Demonstration Program (CRCSDP)

• Grantee Funding– CDC funds 25 States

and 4 tribes/tribal

organizations

– Cooperative agreement

awards range from

approximately $400,000

to $1.5M for a total

awarded amount of

approximately $27M

Colorectal Cancer ScreeningProgram Components

• Screening Promotion (Population-Based)– Emphasis on policy and systems change – Implement Evidence-based strategies (Community

Guide)– Ensure adequate diagnostic and treatment follow-up– Leverage existing resources and infrastructure

• Screening Provision– Direct screening for eligible low income, under- and

uninsured men and women

Flexibility in Grantee Implementation…

§ Screening Provision§ Choose screening tests among USPSTF

recommendations§ Medical Advisory Board & local medical practices§ Unique screening delivery systems§ Unique non-screening support interventions

§ Screening Promotion§ Unique policy and systems change and

intervention strategies§ Unique health communication strategies§ Unique partnerships

• Fact Sheets/Brochures/Posters• Public Service Announcements• English and Spanish Materials• Web Site: www.cdc.gov/screenforlife

Public Awareness:CDC’s Screen for Life National Colorectal Cancer Action Campaign

CRCCP Screening Data

§ Data from initiation of program screening in 2009 through CY 2010

§ 8494 clients *screened

§ 22 cancers diagnosed

§ 1187 cases of precancerous polyps detected and removed

* FOBT, colonoscopy, sigmoidoscopy

CRCCP Status UpdatesYear 1 Progress (Initial 25 grantees)

Grantees are working with key partners identified by CDC

§ 81% with FQHCs and other health care systems § 68% with their State Medicaid Office § 42% with employers and insurers

Grantees are using evidence-based interventions recommended in the Community guide

§ 92% are using small media

§ 69% are promoting the use of client reminders

§ 61% are promoting provider assessment and feedback systems

§ 65% are promoting or supporting the use of patient navigation

CRCCP FQHC Partnership Examples

§ Alabama contracts with the Alabama Primary Care Assn to promote the use of FIT as the standard of care screening test in FQHCs. Subsequently, the FQHC’s adopted a policy to incorporate screening into all age appropriate patient visits.

§ Florida collaborated with ACS and Florida Association of Community Health Centers to conduct training on colorectal cancer screening for member FQHCs. Use of FIT was adopted by the FQHCs.

§ Montana collaborates with the Montana Primary Care Association to disseminate the Community Guide recommendations to FQHCs to increase CRC screening

Disparities in Cancer Burden

Type Indicator TargetScreening PriorityPopulation

Mammography screening age 50 and older

Women rarely/never screened for cervical cancer

>75%

>20%Timely and completeDiagnostic follow-up of abnormal screening results

Breast diagnosis completed

Breast diagnosis completed within 60 days

Cervical diagnosis completed

Cervical diagnosis completed within 90 days

> 90%

>75%

> 90%

> 75%

Timely and complete Treatment initiated for cancers diagnosed

Breast treatment initiated

Breast treatment initiated within 60 days

Cervical treatment initiated

Cervical treatment initiated within 60 days (Invasive)

Cervical treatment initiated within 90 days (CIN2/3)

>90%

>80%

>90%

> 80%

>80%

NBCCEDP Core Quality Performance Indicators

Richardson L et al. Timeliness of Breast Cancer Diagnosis and Initiation of Treatment. AJPH. 2010

Conclusion: “Women screened by the NBCCEDP received diagnostic follow-up and initiated treatment within preestablished program guidelines.”

*CRCCP Core Service Quality Indicators CDC Target

Screening CRCCP Priority Population

Percent of new clients screened who are at average risk for CRC

> 75%

Percent of average risk new clients screened who are age 50 and older

> 95%

Complete clinical follow-up

Diagnostic evaluation is completed for abnormal screening tests

> 90%

Treatment is initiated for cancers diagnosed > 90%

Timelyclinical follow-up

Time from a positive test (FOBT/FIT, Sig, DCBE) to diagnostic colonoscopy is within 90 days

> 80%

Time from cancer diagnosis to treatment is within 60 days

> 80%

CRCCP grantees have been screening approximately 18 months. Quality data are not yet available.

ACA will increase access to cancer screening to millions

• Requires coverage of USPSTF

recommended preventive health services,

grades A and B, w/elimination of cost-

sharing including colorectal, *breast and

cervical cancer screening

• Required for…

– New health insurance plans

– Medicare

– New Medicaid Expansion clients

*For mammography, uses USPSTF recommendations prior to November 2009 updated guidelines

q Outreach

q Care Management

q Quality Assurance

q Organized Approaches

Future Directions in Cancer Screening

Physician recommendation is a

significant motivator to participation in cancer

screening.

Beydoun HA, Predictors of colorectal cancer Screening. Cancer Causes Control; 2008

Percent of adult respondents aged 50-75 years who reported receiving FOBT and/or lower endoscopy within

10 years, BRFSS 2002-2010

Centers for Disease Control and Prevention (CDC).. Vital signs: colorectal cancer screening, incidence, and mortality --- United States, 2002--2010. MMWR Morb Mortal Wkly Rep. 2011 Jul 8;60(26):884-9.

Test Evidence Incidence Reduction

Mortality Reduction

gFOBT Randomized Controlled

Trial

17% - 20% 15% - 33%

Flexible sigmoidoscopy

RandomizedControlled

Trial(UK Sig Trial)

21% 31%

Colonoscopy Based on Statistical Models

No randomized controlled trials

52%-81% 65%-85%

USPSTF Recommendations for CRC Screening

CRCCP Screening Promotion ActivitiesCommunity Guide Recommendations

to Increase CRC Screening

1. *Client reminder systems

2. *Small media (well designed, audience-appropriate informational or motivational videos, brochures, newsletters,, etc.)

3. *Structural barriers (Patient navigation, time and distance barriers, hours of service, clinic environment, administrative barriers, )

4. *Provider assessment and feedback

5. *Provider reminder systems

6. *Multi-component interventions

7. “Other evidence-based, evaluated interventions”

* Community Guide recommendations are based on FOBT. There is insufficient evidence for colonoscopy.

Informed,ActivatedPatient

ProductiveInteractions

Prepared,ProactivePractice Team

Improved Outcomes

DeliverySystemDesign

DecisionSupport

ClinicalInformation

Systems

Self-Management

Support

Health SystemResources and Policies

Community Health Care Organization

Chronic Care Model

This leaflet explains how to use the kit.Please read carefully

http://www.cancerscreening.nhs.uk/bowel/publications/kit-instructions.pdf

CRC Screening: Kaiser Permanente, Northern California

Source: TR Levine, NIH State of the Science Conference: February 2010

CoCaP program

FSIG Capacity Built

FSIG > FOBT

Screening rates followed by survey

1994-2003 2004

HEDIS

Performance Improvement Opportunity

FIT and Guaiac

’05 – ’06

Performance Allocations

Facility-based FOBT CRC Screening pilots

’07 – ’09

Regionally managed mailed FIT outreach

Monitored colonoscopy follow-up

Opportunistic Organized

Colorectal Cancer ScreeningKPNC HEDIS Performance Trend 2004-2010

35%37%

39%

50%

53%

69% 69%

46%

41%

46%

50%

58%

75%

78%

30%

40%

50%

60%

70%

80%

90%

2004 2005 2006 2007 2008 2009 2010

Rate

Commercial Medicare

TR Levine, NCCRT presentation: November 2010

Organized

screening

started in

2005

Collaboration of Public Health and Primary Care in the Community Health Center

Setting

Build on Cancer Screening Infrastructure and History of Collaboration

• Extensive existing NBCCEDP & CRCCP

provider network & delivery system

• Established Quality Assurance System

• State Health Dept Interface through Primary

Care Association/Office of Rural Health

• Infrastructure of Local Health Departments

Implement Benchmarks and Performance Indicators

• Include CRC screening as a UDS measure*

• Adoption of consistent quality performance

measures

• Develop payment systems that incentivize

delivery of screening and other preventive

services

Monitor and Assure Adequate Follow-up and Treatment

• Expand existing CDC reporting system to

all patients who receive screening services

(NBCCEDP providers).

• Adapt system for use across all FQHCs

• Adapt system to Electronic Health Records

Design and Support Practice Systems That Optimize Cancer Screening

• Practice-wide screening registries,

• Systems to prompt provider action,

• Use of standing orders and expedited

screening referral,

• Automated mail-out or telephone screening

reminders for screening or rescreening,

• (Direct mailing of FOBT kits to patients).

Provide Education, Outreach and Patient Support

• Provide effective “Small Media” materials

• Expand use of community outreach

worker models to promote screening

among residents in FQHC “catchment”

areas

• Expand use of patient navigators

Community Oriented Primary Care

For more information please contact Centers for Disease Control and Prevention1600 Clifton Road NE, Atlanta, GA 30333Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348E-mail: cdcinfo@cdc.gov Web: www.cdc.gov

The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Thank You . . .

Marcus Plescia, MD, MPHmplescia@cdc.gov

National Center for Chronic Disease Prevention and Health PromotionDivision of Cancer Prevention and Control

Additional Program Information

41

Social Ecological Model (Simplified)

CRCCP Strategies

• Screening Provision– Screen eligible low-income, uninsured and underinsured

aged 50-64*– Up to 33% of grantee funding used for direct clinical

services

• Screening Promotion– Colorectal cancer screening of populations age >50 – Promote USPSTF guidelines and quality screening– Emphasis on upstream implementation (policy,

organizational/system level) for multiplier effect– Evidence-based strategies (Community Guide)– Leverage existing resources & infrastructures

* Eligible for Medicare begins at age 65

Technical Assistance and TrainingCDC provides grantees…§ Program social ecological

model, program framework, and logic model

§ Data collection TA and performance feedback

§ Ongoing grantee capacity development and training§ TA calls, Webinars and In-

person trainings

§ Program Directors/Data Managers meeting

§ Intervention Action Guides

Grantees provide

information and

training to, and

monitor clinical

providers to

assure quality

screening, follow-

up and tracking.

Oversight, Reporting and Accountabilities

§ CRCCP Screening

Provision Requirementso Screening Eligibility Criteria

o USPSTF Recommended

Screening Tests

o Clinical Guidelines

o Colorectal Cancer Data

Elements (CCDEs)

o Core Service Quality Indicators

(CSQI)

§ CRCCP Screening

Promotion Guidanceo Social Ecological Model

o Program Framework

o Program Logic Model

Oversight, Reporting and Accountabilities

CDC Program Requirements &

Guidance

CDC Notice of Grant Award,

Grantee Program Policies Grantee’s

Clinical Provider Contract

Requirements

Oversight, Reporting & Accountabilities

•Annual Workplans & Budgets•Grantee Interim Progress Reports•Grantee Financial Status Reports

•CDC Status and TA Calls•CDC Site Visits

CCDEsCSQIs

CDC Program Requirements &

Guidance

CDC Notice of Grant Award,

Grantee Program Policies Grantee’s

Clinical Provider Contract

Requirements

CCDEsCSQIs

Diverse CRCCP Grantee Partnerships

Example Partners§ Comprehensive Cancer Control

Coalition§ Association of Community Health

Centers§ State Primary Care Assns§ Indian Health Service§ Cancer Centers§ Quality Improvement Orgs§ Prevent Cancer Foundation§ Medicaid Office§ American Gastroenterological

Association§ Local community-based

organizations

Example Activities§ Fund raising§ Clinical provider network§ Medical Advisory Board§ Health disparities and targeted

client outreach § Policy and systems changes§ Public information/education§ Quality monitoring and

assurance§ Professional education and

training§ Treatment services § Other…

CRCCP FQHC Partnership Examples

§ Nevada contracts with two FQHCs that serve 16-17 counties; these two FQHCs are the primary source of people screened.

§ Delaware’s FQHC partners identify program eligible men and women in their patient population and refer them for screening at five non-profit hospitals (colonoscopy).

§ Washington, Colorado and Utah collaborate with the American Cancer Society to host “Quality Forums” for major health plans and systems to increase the quality of colorectal cancer screening among clinical providers.

CRCCP Medicaid Partnership Example

§ Maryland is partnering with the:

§ Medicaid Office to send 60,000 customized Screen for Life

postcards to age eligible enrollees across the state with

contact information for an appointment and screening

information.

§ Medicaid Managed Care Organization (MCO) to track the

Medicaid screening rates and engage provider offices.

Annual Medicaid data analysis is being done to track

changes in screening as a result of the intervention.

NBCCEDP FQHC Partnership Example

§ New York contracts with the Hudson Headwaters Health

Network (HHHN) , a 13 site FQHC to provide patient

navigation services to rural women in need of breast and

cervical cancer.

§ In six months, the patient navigators contacted 900

HHHN clients; 484 completed cancer screening and 192

are in process.

§ The navigators assisted 177 clients with transportation,

cost barriers to complete their cancer screening through

the use of taxi services, bus fares and gas cards.

CRCCP Program Evaluation

CDC Program Evaluation

– Surveys of Grantee

Screening Promotion

Activities

– CRCCP Impact Study

– CRCCR Cost Analysis

Study

29 CRCCP Grantees

CDC Partnership with National Colorectal Roundtable

§ Member-based , funded by CDC and ACS.

§ Public and private sector entities, voluntary organizations

and selected invited individuals with a special interest in

reducing colorectal cancer incidence and mortality

§ CDC staff are active members:

§ Steering Committee

§ Chairpersons and members of task specific workgroups

CDC Partnership with Prevention Research Centers

§ CPCRN (Cancer Prevention & Control Research Network)

§ MIYO (Make It Your Own) – Web-based

communication tool to create small media products and

patient reminders using evidence-based and tested

messages and visuals (WA University in St. Louis)

§ CRCCP Evidence-Based Use Project –

“Screening Promotion” survey among CRCCP grantees (UW, UNC and Emory; CDC)

CDC Review and Adoption of New Scientific Evidence

§ Internal CDC review of scientific evidence

§ Seek external expert recommendations (as needed)

§ FACA: Mammography screening recommendation for

women aged 40-49 year

§ Ad Hoc External Expert Committee: Program

reimbursement of digital mammography

§ Consideration of program implications and cost§ Develop, disseminate, implement new policy (if

appropriate)

Health Information Technology

§ No integration of CDC and HRSA data systems (a

future opportunity!)

§ CRCCP Colorectal Cancer Data Elements (CCDEs)

§ Demographic and clinical screening data

§ Required submission by grantees (clinical

providers including participating FQHCs)

§ Screening and performance reports provided by

CDC